ZIPPIE IRIS (Transit Included) EIZ5A

Transcription

1 ZIPPIE IRIS (Transit Included) EIZ5A MASS QLD ORDER FORM SUMMARY PAGE Effective: January, 2014 ORDERING INFORMATION: (02) Fax: (02) Date: Sales Rep: Mobile: Signature: Customer Name: MASS Plaque #: MASS PO#: Signature: Prescriber Name: Mobile: Signature: ZIPPIE IRIS PRODUCT INFORMATION Zippie Iris is a fully customisable non-folding tilt-in-space wheelchair designed for the more dependent paediatric user. Zippie Iris is transport-ready and supplied with an extensive range of adjustability and avaiable options to allow the product to be tailored to meet a wide range of user needs. DEALER INFORMATION Name: Fax: CUSTOMER INFORMATION Contact: Fax: PRESCRIBER INFORMATION Organisaton: Fax: ZIPPIE IRIS REHAB SEATING PACKAGE INFORMATION: Zippie Iris is offerred at time of sale with an optional transport-ready rehab seating package. Package includes backrest, headrest AND cushion. To choose this package please itemise your selections below: 0 MASS PAEDIATRIC REHAB SEATING PACKAGE* $1,890 0 UPCHARGE FOR SEAT WIDTH 16 or 18" $100 TOTAL: $0 Please indicate your 3 product selections below: MASS ZIPPIE IRIS STANDARD CONFIGURATION: 0 ANY standard Jay GS, J2, J2 Deep Contour or J3 Cushion: 0 TRANSIT OPTION Yes (Valued at up to $847) 0 SAFE WORKING LOAD 68kg Please indicate required Model #, below: 0 TILT RANGE 45 or 50 degrees 0 WIDTHS 10-18" (please complete J3 Order Form if applicable) 0 DEPTHS 10-18" 0 ANY standard Jay J3 Backrest (transport ready): 0 FRONT SEAT HEIGHTS 15-19" 12/16/20/22/24"" Mag or 0 REAR WHEELS (Valued at up to $995) 20/22/24"" Lite Spoke 0 CASTERS 5/6/8" Polyurethane Please indicate required Model #, below: 0 ARMRESTS Flip-Up, T-style or Dual Post 0 LEGREST HANGERS 70/80/90 degree Swing-In / Out (please complete J3 Order Form if applicable) 0 FOOTPLATES Aluminium Angle Adjustable 0 ANY of the following Whitmyer Headrests (transport ready): 0 WHEEL LOCKS Push to Lock / Foot Wheel Lock (includes mounting system & attachment plate) 0 SEAT Growable Solid Seat Pan (Valued at up to $625) 0 BACKREST Frame Only 0 J3HEDC8 8" Plush Pad with Cobra Mount 0 ACCESSORIES Tool Kit 0 J3HEDC10 10" Plush Pad with Cobra Mount 0 J3HEDC14 14" Plush Pad with Cobra Mount PRICE SUMMARY: 0 J3HEDCCM Medium Contour Cradle on Cobra Mount MASS ZIPPIE IRIS STANDARD PRICE: $0 0 J3HEDCCL Large Contour Cradle on Cobra Mount OPTIONS & ACCESSORIES COST: $0 (See Order Form for details) TOTAL CHAIR PRICE: $0 * Rehab Seating Package includes only standard cushions and backrests - any required options & accessories must be quoted separately * Rehab Seating Package is offerred at a unit price: for purchase of individual SEATING ACCESSORIES COST: $0 items, a separate quote must be supplied. (See Supplier Quote for details) PLEASE NOTE: * Rehab Seating Package is only available for MASS purchase, in conjunction with purchase of selected Breezy, Quickie and Zippie wheelchairs TOTAL MASS PACKAGE PRICE: $0 * Please note that size & weight limits apply to Jay products: please choose seating components to meet individual seating requirements. 1 of 7

2 Account No: Date: P.O. #: Therapist: Customer Name: Rep Name & ZIPPIE IRIS (Transit Included) EIZ5A MASS SOA 25/7/ Effective: January, 2014 ORDERING INFORMATION: (02) Fax: (02) ACCOUNT INFORMATION Ship To: Name: This is an interactive order form when used in an MS Excel application. Please note selections must be made in order, starting from Page 1. To activate it, simply change the "0" to "1". This will highlight the selection for you. Text boxes will pop up as you go through the script, with reminders of what you are able to do. NOTE: Rather than not making any selections, either select Omit or write Omit next to it so that we know it isn t an option. This form can be printed & used manually if required. ZIPPIE IRIS (Transit Included) 0 188WM47 Std. Base and Seat Frame $3,700 0 Secondary Strut tube Kit (Part # ) N/C (Includes True Fit Growth) (Increases or "grows" the chair width by 2") (For full growth use True Fit Programme) Base price includes frame, standard wheels, casters, standard upholstery, standard wheel locks. Client accessories and other options to alter chair perfomance are additional charge. 1. FRAME STYLE 0 188FT46 Contracture Seat Frame N/C 0 188FS29 Battery Tray $330 (N/A with 10" Frame Depth) (N/A with 10" & 11" frame widths or foot wheel lock) 2. TRANSIT SYSTEM 0 188TO22 Transit Included N/C 0 188TO24 Transit Omit N/C 3. TILT RELEASE OPTIONS 0 188TT8 Foot Release - No Cables 0 188TT12 Dual Trigger Cable Release N/C (N/A with Vent and Battery Tray) 0 Left 0 Right (facing from rear) 4. PRE-SET TILT ANGLE 55 Range 40 Range N/A with Reclining Backrest 0 188TA8-5 to 35 N/C 0 188TA5-5 to 50 N/C (N/A with 12.5" STFH) (N/A with 12.5" STFH) 0 188TA9 0 to TA6 0 to TA10 +5 to 45 N/C 0 188TA7 +5 to 60 N/C 5. FRAME COLOUR STANDARD COLOURS 0 188C2 Black $ C11 Toxic Green $0 (N/A as base with Zebra) 0 188C8 Yellow $ C10 Black Opal $ C113 Titanium Paint Colour $ C38 Blue Opal $0 0 White $ C36 Candy Blue $ C14 Candy Purple $ C35 Candy Red $0 CUSTOM COLOURS 0 188C128 Copper $ C120 Mossy Oak Camouflage $ C6 Forest Green $ C123 Stars & Stripes $ C127 Fuchsia $ C108 Zebra $ C126 Glow $0 (Choose above frame colour C116 Matte Black $0 N/A in black. Std white base if no colour is chosen) 0 188C117 Matte Green $ C4 Midnight Purple $ C5 Pearl Pink $ C103 Rootbeer $ C114 Sparkle Silver $0 6. FRAME WIDTH 0 188W1 10" $ W6 15" $ W2 11" $ W7 16" $ W3 12" $ W8 17" $ W4 13" $ W9 18" $ W5 14" 2 of 7

3 7. FRAME DEPTH Choose Selections from Option A or Option B 0 OPTION A - Quickie chooses frame depth based on client information 0 OPTION B - You choose the frame length & seat depth OPTION A: FRAME DEPTH SET-UP BY QUICKIE OPTION B: FRAME DEPTH RANGE Desired Seat Depth 0 188SN01 Short Seat Frame 10" - 14" $0 0 10" 0 188SN02 Medium Seat Frame 12" - 16" $0 0 11" 0 188SN03 Long Seat Frame 14" - 18" $0 0 12" 0 13" OPTION B: FRAME DEPTH 0 14" 0 188FD1 10" recommended with Short Seat Frame. $0 0 15" (N/A with Contracture Footrest System) 0 16" 0 188FD2 11" recommended with Short Seat Frame. $0 0 17" 0 188FD3 12" recommended with Short Seat Frame $0 0 18" 0 188FD4 13" recommended with Med. Seat Frame $ FD5 14" recommended with Med. Seat Frame $0 Back Type (See Figure 7.1) 0 188FD6 15" recommended with Med. Seat Frame $0 0 3" 0 188FD7 16" recommended with Long Seat Frame $0 0 2" 0 188FD8 17" recommended with Long Seat Frame $0 0 1" 0 188FD9 18" recommended with Long Seat Frame $0 0 Flush 0-1" 0-2" Top of Cushion to Seat Rail 0 2.5" or Greater 0 Less than 2.5" () 0 Below Seat Rail SEATS 0 188ST35 Seat Pan-Growable (Fig. 8.1) 0 188ST36 Drop Seat Pan $192 (N/A with 10" frame depth) 0 188ST54 Omit Seat Pan N/C 8. SEATING Seat Pan Size 10" - 16" 14" - 18" REFERENCE ONLY Dim A Range 11-1/4" /4" 15" - 19" SEATING PACKAGE 0 MASS PAED REHAB SEATING PACKAGE $1,890 0 UPCHARGE FOR SEAT WIDTH 16 or 18" $100 Figure Frame Depth Growth Range Matrix 9. STROLLER HANDLE BACK POSTS - BACK RESTS Please choose Option A, Option B or Option C (See Figure 1) 0 Option A: Fixed Height 0 Option B: Height Adjustable With Angle Adj. Push Handles 0 Option C: Reclining Backrest OPTION A: FIXED HEIGHT 0 188BP9 Low (19" Height) N/C 0 188BP10 Medium (22" Height) 0 188BP11 Tall (25" Height) N/C Figure BP13 Removable Extension $ RG1 Folding Adjustable Rigidizer $280 OPTION B: HEIGHT ADJ. WITH ANGLE ADJ. PUSH HANDLES 0 188B170 Std (16" - 22" Height) 0 188PH8 Std Angle Adj. Push Handle Length $ PH9 Long Angle Adj. Push Handle Length $ B171 Tall (19" - 25" Height) N/C 0 188PH8 Std Angle Adj. Push Handle Length $ PH9 Long Angle Adj. Push Handle Length $0 OPTION C: RECLINING BACKREST Only available with 40 Tilt Range 0 188B11225 Medium (21" Height) $1, B11225 Tall (24" Height) $1,712 DYNAMIC BACKREST OPTION N/A with Transit Tie Downs Only available through Built-4-Me 0 183JB01 Dynamic Backrest $1,499 0 Yellow Elastomer 11kg required for deflection 0 Blue Elastomer 18kg required for deflection 0 Red Elastomer 23kg required for deflection A) Reclining / Fixed Handle Height Diagram B) Height Adj. Handle Height Diagram 3 of 7

4 10. ARMRESTS ARMREST & ARMPAD Dual Post N/A with 10-13" deep or with 14-15" deep seat pan ARMREST - HEIGHT ADJUSTABLE Please refer to the matrix below AA12 T-Post Regular with Foam (10" armpad) N/C 0 188AA11 Single-Post Height Adj. Std AA13 T-Post Tall with Foam (10" armpad) N/C 0 188AM23 Desk Classic N/C 0 188AA3 Flip-Up N/C 0 188AM21 Desk Contour N/C 0 10" - 13" 0 188AM24 Full Classic N/C 0 14" - 16" 0 188AM22 Full Contour N/C 0 188AA1 Adjustable Locking Flip-Up $ AA7 Length Adjust. Locking Flip-Up $ AA29 Single-Post Height Adj. Low N/C 0 188AM23 Desk Length (10") 0 188AM23 Desk Classic N/C 0 188AM24 Full Length (14") N/C 0 188AM21 Desk Contour N/C 0 188AM9 Foam Short N/C 0 188AM24 Full Classic N/C 0 188AM10 Foam Long N/C 0 188AM22 Full Contour N/C 0 188AA62 Dual Post N/C 0 188AM23 Desk Classic N/C ARMREST RECEIVER FOR HEIGHT ADJUSTABLE ARMREST 0 188AM21 Desk Contour N/C Please refer to the matrix below AM24 Full Classic N/C 0 188AR17 Low $ AM22 Full Contour N/C 0 188AR18 Std $ AA63 Dual Post Height Adjustable $ AM23 Desk Classic N/C 0 188AM21 Desk Contour N/C 0 188AM24 Full Classic N/C 0 188AM22 Full Contour N/C 0 188AA43 Dual Post Flip Back $ AM23 Desk Classic N/C 0 188AM21 Desk Contour N/C 0 188AM24 Full Classic N/C 0 188AM22 Full Contour N/C 0 188AA48 Dual Post Flip Back Height Adj. $ AM23 Desk Classic N/C 0 188AM21 Desk Contour N/C 0 188AM24 Full Classic N/C 0 188AM22 Full Contour N/C Armrest Matrix for Single Post Armrest Size Transfer Tube Length D Receiver H Range CLASSIC PAD Full 8" 5 1/4" 10 3/4" to 15 3/4" 8 3/4" to 13 3/4" 9" to 13" 7 1/4" to 11 1/4" 14" CONTOUR PAD Receiver H Range Full 10" to 15" 8 1/4" to 12 1/2" 8 1/2" to 12 1/2" 14 1/4" 6 3/4" to 10 3/4" 4 of 7

5 11. FOOTRESTS Please choose one of the Options below:- 0 Option 1: Hanger Mounted (Footplates Mount to Hanger Tubing) 0 Option 2: Ext. Tube Mounted (Footplates Mount to Extension Tube) 0 Option 3: Contracture System OPTION 1: HANGER MOUNTED FOOTREST FOOTREST HANGER OPTIONS (Option 1 and 2 only) Hanger Type 0 188IG2 Neoprene Covers $ H89 70 Swing In / Out Front Mount (Avail. on 60 / 70 / 80 ext. mount hangers only) 0 188H90 80 Swing In / Out Front Mount N/C 0 188A54 Extra Single Leg Strap $ H91 90 Swing In / Out Front Mount N/C 0 188A110 Toe Loop $ H9 70 Heavy Duty Front Mount Lift-Off $192 (Only avail. with adult angle adjust. footplates) 0 188H10 80 Heavy Duty Front Mount Lift-Off $ H32 Omit Hanger -$ H11 90 Heavy Duty Front Mount Lift-Off $ F7 Omit Footplate and Ext. Tube -$ H23 90 Elevating $ HL4 Omit Heel Loop N/C Extensions (may interfere with some seat Heights & casters) 0 188HL6 Omit Single Leg Strap N/C 0 188E23 2" (Not mounted) $ E24 4" (Not mounted) $51 Footplate 0 188F9 Kids Angle Adjustable with Leg Strap $121 (N/A with 17" - 18" widths) 0 188F8 Adult Angle Adj. with Heel Loops $121 (Available with 17" - 18" widths) 0 188F62 Footboard with Leg Strap $121 (Available with 10" - 16" widths) OPTION 2: EXT. TUBE MOUNTED FOOTRESTS OPTION 3: CONTRACTURE FOOTREST SYSTEM (CFS) Hanger Type Multi-Adj. Padded Hangers & Angle Adj. Aluminium Footrests H85 60 Swing In / Out N/C N/A with Dual Post Armrest H86 70 Swing In / Out 0 188H Swing In / Out N/C 0 188FP01 CFS - Centre Mount $ H24 Articulating $ FP02 CFS - Outside Mount $ H14 Elevating $310 (N/A with composite or platform footplates) 0 188E1 SHORT N/C 0 188EP1 10.5" Extension Height $0 Extensions 0 188EP2 11.0" Extension Height $ E1 Short (11.5" - 14") N/C 0 188EP3 11.5" Extension Height $ E2 Medium (14" - 17") 0 188EP4 12.0" Extension Height $0 (N/A with Elevating Legrests) 0 188EP5 12.5" Extension Height $ E5 Long (17" - 19") N/C 0 188EP6 13.0" Extension Height $ E16 High Mount $ E2 REGULAR N/C Footplate 0 188EP5 12.5" Extension Height $ F1 Composite with Heel Loops N/C 0 188EP6 13.0" Extension Height $0 (N/A in 10", 11" or 12" width) 0 188EP7 13.5" Extension Height $ F3 Adult Angle Adjustable with Heel Loops N/C 0 188EP8 14.0" Extension Height $ F4 Kids Angle Adjustable with Leg Strap 0 188EP9 14.5" Extension Height $0 (N/A with 17" - 18" width) 0 188EP " Extension Height $ F5 Aluminium N/C (Only available with elevating legrests 14" - 18") 0 188F48 Platform Flip-Up with Leg Strap $252 (Avail on 60 / 70 / 80 ext. mount hangers only) 5 of 7

6 12. CASTERS CASTER WHEEL 0 188CW31 4" Micro LigHeight Up $ CW44 4" x 1.25" Semi-Pneumatic N/C 0 188CW51 5" Micro LigHeight Up $ CW5 5" Low-Profile Polyurethane N/C 0 188CW7 5" x 1.5" Semi-Pneumatic N/C 0 188CW33 6" Pneumatic N/C 0 188CW34 6" Polyurethane N/C 0 188CW35 6" x 1.5" Semi-Pneumatic 0 188CW21 8" Pneumatic $ CW32 8" Polyurethane N/C 0 188CW39 8" x 1.5" Semi-Pneumatic $ CW36 8" x 2" Pneumatic $ CW37 8" x 2" Pneumatic with Airless Insert $252 Please select the front seat height in the Matrix to the right, then select the value from the drop down box below. FRONT SEAT HEIGHT Please check the matrix to choose STFH, then select from the Drop-Down List below 0 Front Seat Height based on Rear Wheel Size & Caster Size Click Here to Select a Value from 12.5" to 19" Rear Wheel Size Low Poly CASTER SIZE x AXLES AND WHEELS ONE ARM DRIVE REAR WHEEL SIZE 0 188AL17 One Arm Drive $1, RW13 12" Mag (Avail. with 20", 22", 24" Mag Rear Wheels) (N/A with handrims) 0 188OA2 Standard Handrim $ RW14 16" Mag N/C 0 188HM1 Right $0 (N/A with handrims) 0 188HM2 Left $ RW3 20" Mag N/C 0 188OA1 Small Handrim $ RW8 22" Mag N/C 0 188HM1 Right $ RW1 24" Mag N/C 0 188HM2 Left $ RW90 20" Lite Spoke N/C 0 188RW91 22" Lite Spoke N/C AXLE 0 188RW92 24" Lite Spoke N/C 0 188AX26 One Arm Drive Axle N/C (Only avail. with One Arm Drive Option) HUB LOCK (locking hub design where pin locks hub of wheel) 0 188AX1 Quick Release *Only available with 12" or 16" wheels AX11 Quad Quick Release $168 N/A with one arm drive. (N/A with Lite Spokes) 0 188LK01 12" Hub Lock $ LK02 16" Hub Lock $151 REAR WHEEL TYPE 0 188RT1 Pneumatic WHEEL LOCK 0 188RT2 Pneumatic Airless Insert $185 N/A with Hub Lock 0 188RT3 Full Polyurethane N/C 0 188WL34 High Mount Push N/C (N/A with 12" & 16" rear wheels) 0 188WL36 Foot Lock 0 188RT4 Low Polyurethane N/C 0 188WL10 Omit N/C (Only available with 12" wheels ) 0 188RT8 Kevlar $81 EXTENSION HANDLE (Only available with 24" wheels) 0 188EH1 6" Pair $30 HANDRIM N/A on 12" & 16" Wheels HR1 Aluminium Anodized 0 188HR4 Plastic Coated $ HR7 Omit -$20 (N/A with wheel / axle credit) ANTI-TIP 0 188AT1 Rear Anti-Tip $100 PROJECTIONS Only available with 24" wheels & N/A with spoke guards N/A on Plastic Coated Handrims 0 188HR8 8 Oblique $28 6 of 7

7 BACKPACK 0 188A1 Black Utility Backpack $61 SPOKE GUARD 0 188A7 Black Kids $ A23 Black $108 SEAT POUCH 0 188A8 Black $49 UPPER EXTREMITY SUPPORT TRAY 0 188A24 Clear $ A29 X-Sm (Suggested 10" - 12" Width) $300 MISCELLANEOUS 0 188A30 Sm (Suggested 13" - 14" Width) $ A83 Tool Kit 0 188A31 Med (Suggested 15" - 17" Width) $300 POSITIONING BELT 0 188A112 1" Dual Pull Side Squeeze Padded SIDE GUARD 0 188A32 Lge (Suggested 18" - 20" Width) $ A12 Belt 2" Aircraft Buckle $154 N/A with Height adjustable armrests or T-Posts 0 188A13 Belt 2" Aircraft Buckle Padded $ SG33 Plastic Std $ A141 Belt 1.5" Auto Buckle with Clamps $ SG29 Plastic Low $ A814 1" Comfort Fit APB5116 $129 DOES YOUR CHAIR REQUIRE B4ME? Please remember to fill out the B4Me Order Form. The order will need to be Quoted first, to see if the job is doable. 14. ACCESSORIES N/A with 12" & 16" rear wheels & Projections Handrims CANOPY (SUNSHADE) Needs 2" back post clearance to mount canopy hardware. May require next height based on seating. Some interface may occur with some height configurations A06 Canopy (Sunshade) 10-14" wide $ A07 Canopy (Sunshade) 15-20" wide $249 JAY cushion or Back - see applicable order forms & Jay Retail Price Book Whitmyer - see applicable order form & Whitmyer Short Ordering Guide ART - see relevant price list Have you remembered to order:- NOTE: All additional items, incl. Jay, Whitmyer etc. should be put on your PO, & will be charged at RRP less discount. OTHER products also available for purchase include:- Hoists & Slings, Scooters, Power Wheelchairs, Manual Wheelchairs (including Positioning), Breezy Everyday, Breezy, Quickie Parts NOTE : If more than 1 of a particular part is required, the 2nd part will be charged at RRP less discount (not at "on chair" price). DISCLAIMER: Not all features & options offered are compatible with all configurations of the wheelchair. SPECIALISED DEPARTMENT NOTE: These are specialised items and will add 2 weeks to the delivery time. These items can be added to the wheelchair by Sunrise after it s been ordered. They will be charged at RRP less dealer discount (i.e. not calculated in chair price), & will incur a 1hr labour charge of RRP$100 + GST. 0 DBK12" Attendant brakes with 12" wheels (MAG ONLY) $595 0 DBK16" Attendant brakes with 16" wheels (SPOKE ONLY) $595 0 DBK24" Attendant brakes with 24" wheels (SPOKE ONLY) $595 0 SSRBRZ Stump Support Right $128 0 SSLBRZ Stump Support Left $128 0 B4ME Built 4 Me - PLS CALL CUSTOMER SERVICE POA - DNP Labour 1hr (DNP incl. GST) $ Labour 2hrs (DNP incl. GST) $220 SPARE PARTS: $0 LABOUR (Incl. GST): $0 TOTAL FOR PARTS & LABOUR: $0 NET COST OF CHAIR ONLY: $0 Download a QR reader to your Smartphone to access the Zippie Iris product page. TOTAL COST OF CHAIR, PARTS & LABOUR: $0 7 of 7